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Long, Dorothy , 630 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit 47 Name First Middle Last Sex Dorothy Jean Long Female Date of Death Age If Veteran of U.S. Armed Forces, 08/02/2018 88 Years War or Dates Place of Death Hospital, Institution or - City, Town or Village Glens Falls Street Address Glens Falls Hospital 1 Manner of Death©Natural Cause El Accident Homicide 0 Suicide ❑Undetermined Pending Circumstances Investigation Medical Certifier Name Title Suzanne Rayeski DO row Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 368 vik ❑Burial Date Cemetery or Crematory 08/03/2018 Pine View Crematory pi 0 Entombment Address ®Cremation Queensbury Town, New York Date Place Removed ✓ ❑Removal and/or and/or Held Address Hold Date Point of Q Transportation Shipment by Common Destination • Carrier Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address • Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 14 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address r te Permission is hereby granted to dispose of the human remains described above as indicated. 77 Date Issued 08/03/2018 Registrar of Vital Statistics 106ertA Curtis(Electronicaliy Signed) (signature) District Number 5601 Place Glens Falls, New York • I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition $ I L((g Place of Disposition l ill i-) (t\ (address) (section) (lot umber) r (grave number) • Name of Sexton or Person in Charge of Premises sei r,. nt) i/s^ • Signature b (pl Title '►VIL (over) DOH-1555 (02/2004)